SUBSTANCE DEPENDENCE/ABUSE REHABILITATION

Many drugs and volatile substances are subject to abuse. This disorder is a continuum of phases incorporating a cluster of cognitive, behavioral, and physiologic symptoms that include loss of control over use of the substance and a continued use of the substance despite adverse consequences. A number of factors have been implicated in the predisposition to abuse a substance: biologic, biochemical, psychologic (including developmental), personality, sociocultural and conditioning, and cultural and ethnic influences. While no single theory adequately explains the etiology of this problem, many treatment approaches, such as Alcoholics Anonymous (AA) and harm reduction, are being successful. Care Setting Inpatient stay on behavioral unit or outpatient care in a day program or community agency. Related Concerns Alcohol: acute withdrawal Psychosocial aspects of care Client Assessment Database Depends on substances involved, duration of use, and organs affected. A comprehensive assessment should include questions regarding factors that protect and minimize the risk of substance use. These factors are grouped into five general domains: 1. Community (e.g., availability of substances) 2. Family (e.g., discipline, conflict, attitudes, communication) 3. Peer/individual (e.g., the individuals delinquency, perception of risk, friends attitudes and use of substances) 4. Work/school (e.g., attendance, performance, grades) 5. General (e.g., participation in activities, religious beliefs) Teaching/Learning Discharge plan considerations: May need assistance with long-range plan for recovery Refer to section at end of plan for postdischarge considerations. Diagnostic Studies Serum, urine, and/or hair drug screens: Identifies drug(s) being used, including usual drugs of abuse (e.g., alcohol, heroin, marijuana, cocaine, inhalants). Newer designer drugs, e.g., ketamine and ecstasy, are often not screened for because of the expense. Screening for use/relapse: Variety of tools may be used (e.g., alcohol use disorders screening test [AUDIT], alcohol abuse/dependence screener [CAGE], drug abuse/dependence screener [DAST]) Addiction Severity Index (ASI) assessment tool: Produces a problem severity profile of the client, including chemical, medical, psychologic, legal, family/social, and employment/support aspects, indicating areas of treatment needs.

Other screening studies (e.g., hepatitis, HIV, TB): Depends on general condition, individual risk factors, and care setting. Nursing Priorities 1. Provide support for decision to stop substance use/harm reduction. 2. Strengthen individual coping skills. 3. Facilitate learning of new ways to reduce anxiety. 4. Promote family involvement in rehabilitation program. 5. Facilitate family growth/development. 6. Provide information about condition, prognosis, and treatment needs. Discharge Goals 1. Responsibility for own life and behavior assumed. 2. Plan to maintain substance-free life formulated. 3. Family relationships/enabling issues being addressed. 4. Treatment program successfully begun. 5. Condition, prognosis, and therapeutic regimen understood. 6. Plan in place to meet needs after discharge. NURSING DIAGNOSIS: Denial May be related to Personal vulnerability, difficulty handling new situations Previous ineffective/inadequate coping skills with substitution of drug(s) Learned response patterns, cultural factors, personal/family value systems Possibly evidenced by Delay in seeking or refusal of healthcare attention to the detriment of health/life Does not perceive personal relevance of symptoms or danger or admit impact of condition on life pattern projection of blame/responsibility for problems Use of manipulation to avoid responsibility for self DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL: Acceptance: Health Status (NOC) Verbalize awareness of relationship of substance abuse to current situation. Engage in therapeutic program. Verbalize acceptance of responsibility for own behavior.

ACTIONS/INTERVENTIONS Behavior Modification (NIC) Independent Ascertain by what name client would like to be addressed. Convey attitude of acceptance, separating individual from unacceptable behavior. Ascertain reason for beginning abstinence, involvement in therapy.

RATIONALE

Shows courtesy and respect, giving client a sense of orientation and control. Promotes feelings of dignity and selfworth. Provides insight into clients willingness to commit to long-term behavioral change, and whether client even believes that he or she can change. (Denial is one of the strongest and most resistant symptoms of substance abuse.) The decision to quit is an important step to success in therapy. This information helps client make decisions regarding acceptance of problem and treatment choices. Creates trust, which is the basis of the therapeutic relationship. Progression of use continuum is from experimental/recreational to addictive use. Comprehending this process is important in combating denial. Education may relieve clients guilt and blame and may help awareness of recurring addictive characteristics. First step in decreasing use of denial is for client to see the relationship between substance use and personal problems. Because denial is the major defense mechanism in addictive disease, confrontation by peers can help the client accept the reality of adverse consequences of behaviors and that drug use is a major

Review definition of drug dependence and categories of symptoms (e.g., patterns of use, impairment caused by use, tolerance to substance). Answer questions honestly and provide factual information. Keep your word when agreements are made. Provide information about addictive use versus experimental, occasional use; biochemical/genetic disorder theory (genetic predisposition, use activated by environment; compulsive desire.)

Discuss current life situation and impact of substance use. Confront and examine denial/ rationalization in peer group. Use confrontation with caring.

problem. Caring attitude preserves selfconcept and helps decrease defensive response. Provide information regarding effects of addiction on mood/personality. Individuals often mistake effects of addiction and use this to justify or excuse drug use.

Remain nonjudgmental. Be alert to changes Confrontation can lead to increased in behavior; e.g., restlessness, increased agitation, which may compromise safety of tension. client/staff. Provide positive feedback for expressing awareness of denial in self/others. Maintain firm expectation that client attend recovery support/therapy groups regularly. Necessary to enhance self-esteem and to reinforce insight into behavior. Attendance is related to admitting need for help, to working with denial, and for maintenance of a long-term drug-free existence. Denial can be replaced with positive action when client accepts the reality of own responsibility.

Encourage and support clients taking responsibility for own recovery (e.g., development of alternative behaviors to drug urge/use). Assist client to learn own responsibility for recovering. Be aware of own enabling behaviors.

Caregiving lends itself to taking care of clients that can backfire in substance abuse treatment.

NURSING DIAGNOSIS: ineffective Coping May be related to Personal vulnerability Negative role modeling, inadequate support systems Previous ineffective/inadequate coping skills with substitution of drug(s) Possibly evidenced by Impaired adaptive behavior and problem-solving skills Decreased ability to handle stress of illness/hospitalization Financial affairs in disarray, employment/school difficulties (e.g., losing time on job/not maintaining steady employment; poor work/school performances, onthe-job injuries)

Verbalization of inability to cope/ask for help DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL: Substance Addiction Consequences (NOC) Identify consequences of using substance as a method of coping. Coping (NOC) Identify other ineffective coping behaviors. Engage in effective coping skills/problem solving. Initiate necessary lifestyle changes.

ACTIONS/INTERVENTIONS Substance Use Treatment (NIC) Independent Review program rules, philosophy expectations.

RATIONALE

Having information provides opportunity for client to cooperate and function as a member of the group/milieu, enhancing sense of control and sense of success. Provides information about degree of denial, acceptance of personal responsibility/commitment to change; identifies coping skills that may be used in present situation. Client has learned manipulative behavior throughout life and needs to learn a new way of getting needs met. Following through on consequences of failure to maintain limits can help the client to change ineffective behaviors. Use of labels promotes negative attitudes that can impede therapeutic relationships. Lack of understanding, judgmental/ enabling behaviors can result in inaccurate data collection and nontherapeutic approaches. May help client begin to come to terms with long-unresolved issues. Client may have little or no knowledge of adaptive responses to stress and needs to learn other options for managing time, feelings, and relationships without drugs. Helps client relax, develop new ways to deal with stress, problem solve. Discovery of alternative methods of coping with drug hunger can remind client that addiction is a lifelong process and

Determine understanding of current situation and previous/other methods of coping with lifes problems.

Set limits and confront efforts to get caregiver to grant special privileges, making excuses for not following through on behaviors agreed on, and attempting to continue drug use. Avoid use of labels, such as lying.

Be aware of staff attitudes, feelings, and enabling behaviors.

Encourage verbalization of feelings, fears, and anxiety. Explore alternative coping strategies.

Assist client to learn/encourage use of relaxation skills, guided imagery, visualizations. Structure diversional activity that relates to recovery (e.g., social activity within support group), wherein issues of being

chemically free are examined. Use peer support to examine ways of coping with drug hunger.

opportunity for changing patterns is available. Self-help groups (e.g., AA, Narcotics Anonymous, Crystal Methamphetamine Anonymous) are valuable for learning and promoting abstinence in each member, using understanding and support as well as peer pressure. Note: Methamphetamine is increasing in use.

Identify possible/actual triggers for relapse. Employment/financial stressors, isolation, Encourage client to use the acronym HALT unhealthy relationships/being around (Am I hungry, angry, lonely, or tired?). substance-using friends, hearing certain songs, premenstrual syndromethe list of possibilities depends on the individual. Being aware of the triggers provides an opportunity to plan for ways to avoid/deal with them. Encourage involvement in therapeutic writing. Have client begin journaling or writing autobiography. Therapeutic writing/journaling can enhance participation in treatment; serves as a release for grief, anger, and stress; provides a useful tool for monitoring clients safety; and can be used to evaluate clients progress. Autobiographical activity provides an opportunity for client to remember and identify sequence of events in his or her life that relate to current situation. Provides opportunity to develop/refine plans. Devising a comprehensive strategy for avoiding relapses helps client into maintenance phase of behavioral change.

Discuss clients plans for living without drugs.

Collaborative Administer medications as indicated; e.g.: Disulfiram (Antabuse); This drug can be helpful in maintaining abstinence from alcohol while other therapy is undertaken. By inhibiting alcohol oxidation, the drug leads to an accumulation of acetaldehyde with a highly unpleasant reaction if alcohol is consumed.

Metronidazole (Flagyl);

Increasingly used to maintain abstinence from alcohol instead of Antabuse. It has the same GI distress effects but fewer cardiac concerns and less cost. Helps prevent relapses in alcoholism by lowering receptors for the excitatory neurotransmitter glutamate. This agent may become drug of choice because it does not make the user sick if alcohol is consumed; it has no sedative, antianxiety, muscle relaxant or antidepressant properties and produces no withdrawal symptoms. Used in the treatment of opioid addiction. At low doses it produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms. This drug carries a lower risk of abuse, dependence, and side effects compared to full opioid agonists. levo-Methadone is thought to blunt the craving for/diminish the effects of opioids and is used to assist in withdrawal and longterm maintenance programs. It can allow the individual to maintain daily activities and ultimately withdraw from drug use. LAAM is a long-acting synthetic agonist thought to be a safe and effective alternative to methadone maintenance. Harm-reduction needs to be considered versus the possibility of exchanging one addiction for another. Used to suppress craving for opioids and may help prevent relapse in the client abusing alcohol. Current research suggests that naltrexone suppresses urge to continue drinking by interfering with alcohol-induced release of endorphins.

Acamprosate (Campral EC);

Buprenorphine (Buprex, Subutex, Suboxone);

Methadone (Dolophine), acetymethadol (LAAM);

Naltrexone (Trexan), nalmefine (Revex).

Encourage involvement with self-help associations; e.g., Alcoholics/Narcotics Anonymous. Refer to community/social resources e.g., housing assistance, employment agencies, childcare, food stamps, alternative schooling.

Puts client in direct contact with support system necessary for managing sobriety/drug-free life. Dealing with life problems in a proactive way enhances coping abilities, reduces sense of isolation and hopelessness, and decreases risk of relapse.

NURSING DIAGNOSIS: Powerlessness May be related to Substance addiction with/without periods of abstinence Episodic compulsive indulgence; attempts at recovery Lifestyle of helplessness Possibly evidenced by Ineffective recovery attempts, statements of inability to stop behavior/requests for help Continuous/constant thinking about drug and/or obtaining drug Alteration in personal, occupational, and social life DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL: Health Beliefs: Perceived Control (NOC) Admit inability to control drug habit, surrender to powerlessness over addiction. Verbalize acceptance of need for treatment and awareness that willpower alone cannot control abstinence. Engage in peer support. Demonstrate active participation in program. Regain and maintain healthy state with a drug-free lifestyle.

ACTIONS/INTERVENTIONS Self-Responsibility Facilitation (NIC) Independent Use crisis intervention techniques to initiate behavior changes:

RATIONALE

May need to use emergency commitments or other legal holds for the clients safety. Client may be more amenable to acceptance of need for treatment at this time. In the precontemplation phase, the client has not yet identified that drug use is problematic. While client is hurting, it is easier to admit substance use has created negative consequences. During the contemplation phase, the client realizes a problem exists and is thinking about a change of behavior. The client is committed to the outcomes when the decision-making process involves solutions that are promulgated by the individual. Brainstorming helps creatively identify possibilities and provides sense of control. During the preparation phase, minor action may be taken as individual organizes resources for definitive change. As possibilities are discussed, the most useful solution becomes clear. Helps the client persevere in process of change. During the action phase, the client engages in a sustained effort to maintain sobriety, and mechanisms are put in place to support abstinence. Client may need assistance in expressing self, speaking about powerlessness, and admitting need for help in order to face up to problem and begin resolution.

Assist client to recognize problem exists. Discuss in a caring, nonjudgmental manner how drug has interfered with life;

Involve client in development of treatment plan, using problem-solving process in which client identifies goals for change and agrees to desired outcomes;

Discuss alternative solutions;

Assist in selecting most appropriate alternative; Support decision and implementation of selected alternative(s).

Explore support in peer group. Encourage sharing about drug hunger, situations that increase the desire to indulge, ways that substance has influenced life.

Assist client to learn ways to enhance health and structure healthy diversion from drug use (e.g., maintaining a balanced diet, getting adequate rest, exercise [e.g., walking, slow/long distance running]; and acupuncture, biofeedback, deep meditative techniques).

Learning to empower self in constructive areas can strengthen ability to continue recovery. These activities help restore natural biochemical balance, aid detoxification, and manage stress, anxiety, use of free time. These diversions can increase self-confidence, thereby improving self-esteem. Note: Exercise promotes release of endorphins, creating a feeling of well-being. Understanding these concepts can help the client to begin to deal with past problems/losses and prevent repeating ineffective coping behaviors and selffulfilling prophecies. Although not mandatory for recovery, surrendering to and faith in a power greater than oneself has been found to be effective for many individuals in substance recovery; may decrease sense of powerlessness. Effective in helping refrain from use, to stop contact with users and dealers, to build healthy relationships, regain control of own life. Helps client know what to expect, and creates opportunity for client to be a part of what is happening and make informed choices about participation/outcomes.

Provide information regarding understanding of human behavior and interactions with others; e.g., transactional analysis. Assist client in self-examination of spirituality, faith.

Instruct in and role-play assertive communication skills.

Provide treatment information on an ongoing basis.

Collaborative Refer to/assist with making contact with Continuing treatment is essential to programs for ongoing treatment needs; e.g., positive outcome. Follow-through may be partial hospitalization drug treatment easier once initial contact has been made. programs, Narcotics/Alcoholics Anonymous, peer support group.

NURSING DIAGNOSIS: altered Nutrition: less than body requirements

May be related to Insufficient dietary intake to meet metabolic needs for psychologic, physiologic, or economic reasons Possibly evidenced by Weight loss, weight below norm for height/body build, decreased subcutaneous fat/muscle mass Reported altered taste sensation, lack of interest in food Poor muscle tone Sore, inflamed buccal cavity Laboratory evidence of protein/vitamin deficiencies DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL: Nutritional Status (NOC) Demonstrate progressive weight gain toward goal with normalization of laboratory values and absence of signs of malnutrition. Knowledge: Treatment Regimen (NOC) Verbalize understanding of effects of substance abuse, reduced dietary intake on nutritional status. Demonstrate behaviors, lifestyle changes to regain and maintain appropriate weight.

ACTIONS/INTERVENTIONS Nutrition Therapy (NIC) Independent Assess height/weight, age, body build, strength, activity/rest level. Note condition of oral cavity. Take anthropometric measurements; e.g., triceps skinfold, when available. Note total daily calorie intake. Recommend client maintain a diary of intake, as well as times and patterns of eating. Evaluate energy expenditure (e.g., pacing or sedentary), and establish an individualized exercise program.

RATIONALE

Provides information about individual on which to base caloric needs/dietary plan. Type of diet/foods may be affected by condition of mucous membranes and teeth. Calculates subcutaneous fat and muscle mass to aid in determining dietary needs. Information will help identify nutritional needs/deficiencies. Activity level affects nutritional needs. Exercise enhances muscle tone, may stimulate appetite.

Provide opportunity to choose foods/snacks Enhances participation/sense of control, to meet dietary plan. may promote resolution of nutritional deficiencies, and helps evaluate clients understanding of dietary teaching. Recommend monitoring weight weekly. Provides information regarding effectiveness of dietary plan.

Collaborative Consult with dietitian. Useful in establishing individual dietary needs/plan and provides additional resource for learning. Identifies anemias, electrolyte imbalances, and other abnormalities that may be present, requiring specific therapy. Teeth are essential to good nutritional intake and dental hygiene/care is often a neglected area in this population.

Review laboratory studies as indicated, (e.g., glucose, serum albumin/prealbumin, electrolytes). Refer for dental consultation as necessary.

NURSING DIAGNOSIS: chronic low Self-Esteem May be related to Social stigma attached to substance abuse, expectation that one controls behavior Negative role models, abuse/neglect, dysfunctional family system Life choices perpetuating failure, situational crisis with loss of control over life events Biochemical body change (e.g., withdrawal from alcohol/other drugs) Possibly evidenced by Self-negating verbalization, expressions of shame/guilt Evaluation of self as unable to deal with events, confusion about self, purpose or direction in life Rationalizing away/rejecting positive feedback about self DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL: Self-Esteem (NOC) Identify feelings and underlying dynamics for negative perception of self. Verbalize acceptance of self as is and an increased sense of self-worth. Set goals and participate in realistic planning for lifestyle changes necessary to live without drugs.

ACTIONS/INTERVENTIONS Self-Esteem Enhancement (NIC) Independent Provide opportunity for and encourage verbalization/discussion of individual situation.

RATIONALE

Client often has difficulty expressing self, even more difficulty accepting the degree of importance substance has assumed in life and its relationship to present situation.

Assess mental status. Note presence of Many clients use substances in an attempt other psychiatric disorders (dual diagnosis). to obtain relief from depression or anxiety, which may predate use and/or be the result of substance use. Approximately 60% of substance-dependent clients have underlying psychologic problems, and treatment for both is imperative to achieve/maintain abstinence. Spend time with client. Discuss clients behavior/use of substance in a nonjudgmental way. Provide grief counseling as indicated. The nurses presence conveys acceptance of the individual as a worthwhile person. Discussion provides opportunity for insight into the problems abuse has created for the client. Life losses secondary to alcohol/drug abuse problems need to be addressed to enable client to move on with rehabilitation. Failure and lack of self-esteem have been problems for this client, who needs to learn to accept self as an individual with positive attributes. Substance abuse is a family disease, and how the members act and react to the clients behavior affects the course of the disease and how client sees self. Many unconsciously become enablers, helping the individual to cover up the consequences of the abuse. (Refer to ND: dysfunctional Family Processes: alcoholism, following.) The client often has lost respect for self and

Provide reinforcement for positive actions and encourage client to accept this input.

Observe family interactions/SO dynamics and level of support.

Encourage expression of feelings of guilt, shame, and anger.

believes that the situation is hopeless. Expression of these feelings helps client begin to accept responsibility for self and take steps to make changes. When drugs can no longer be blamed for the problems that exist, client can begin to deal with the problems and live without substance use. Confrontation helps client accept the reality of the problems as they exist. There are things in everyones life that have been successful. Often when selfesteem is low, it is difficult to remember these successes or to view them as successes. Assists client to practice developing skills to cope with new role as a person who no longer uses or needs drugs to handle lifes problems. Group sharing helps encourage verbalization because other members of group are in various stages of abstinence from drugs and can address the clients concerns/denial. The client can gain new skills, hope, and a sense of family/community from group participation. Clients who seek relief for other mental health problems through drugs will continue to do so once discharged. Both the substance use and the mental health problems need to be treated together to maximize abstinence potential. Treatment may be difficult because of difficulty of taking initiative, thinking realistically, and problem solving. Behavioral methods seem to be most helpful.

Help client acknowledge that substance use is the problem and that problems can be dealt with without the use of drugs. Confront the use of defenses; e.g., denial, projection, rationalization. Ask client to list and review past accomplishments and positive happenings.

Use techniques of role rehearsal.

Collaborative Involve client in group therapy.

Formulate plan to treat other mental illness problems.

Administer antipsychotic medications, quetiapine (Serequel), olanzapine (Zyprexa/Zydis), as necessary.

Prolonged/profound psychosis following lysergic acid diethylamide (LSD) or phencyclidine (PCP) use can be treated with these drugs because it is probably the result of an underlying functional psychosis that has now emerged. Methamphetamine psychosis often does not reverse. Note: Avoid the use of phenothiazines because they may decrease seizure threshold and cause hypotension in the presence of LSD/PCP use. Atypical antipsychotics (e.g., Zyprexa) are associated with these effects and should be monitored closely for changes in glucose control. Measurement of fasting blood glucose at the beginning of therapy and periodical monitoring during therapy are recommended.

Monitor for diabetes, weight gain, and dyslipidemia.

NURSING DIAGNOSIS: dysfunctional Family Processes: alcoholism [substance abuse] May be related to Abuse of substance(s), resistance to treatment Family history of substance abuse Addictive personality Inadequate coping skills, lack of problem-solving skills Possibly evidenced by Anxiety, anger/suppressed rage, shame, and embarrassment Emotional isolation/loneliness, vulnerability, repressed emotions Disturbed family dynamics, closed communication systems, ineffective spousal communication and marital problems Altered role function/disruption of family roles Manipulation, dependency, criticizing, rationalization/denial of problems Enabling to maintain drinking (substance abuse), refusal to get help/inability to accept and receive help appropriately DESIRED OUTCOMES/EVALUATION CRITERIAFAMILY WILL: Family Coping (NOC) Verbalize understanding of dynamics of enabling behaviors. Participate in individual family programs.

Identify ineffective coping behaviors and consequences. Initiate and plan for necessary lifestyle changes. Take action to change self-destructive behaviors/alter behaviors that contribute to partners/SOs addiction.

ACTIONS/INTERVENTIONS Substance Use Treatment (NIC) Independent Review family history, explore roles of family members, circumstances involving drug use, strengths, areas for growth.

RATIONALE

Determines areas for focus, potential for change.

Explore how the SO has coped with the The person who enables also suffers from clients habit (e.g., denial, repression, the same feelings as the client and uses rationalization, hurt, loneliness, projection). ineffective methods for dealing with the situation, necessitating help in learning new/effective coping skills. Determine understanding of current situation and previous methods of coping with lifes problems. Assess current level of functioning of family members. Determine extent of enabling behaviors being evidenced by family members, explore with each individual and client. Provides information on which to base present plan of care. Affects individuals ability to cope with situation. Enabling is doing for the client what he or she needs to do for self (rescuing). People want to be helpful and do not want to feel powerless to help their loved one stop substance use and change the behavior that is so destructive. However, the substance abuser often relies on others to cover up own inability to cope with daily responsibilities. Awareness and knowledge of behaviors (e.g., avoiding and shielding, taking over responsibilities, rationalizing, and subserving) provide opportunity for individuals to begin the process of change. Even though family member(s) may verbalize a desire for the individual to become substance free, the reality of interactive dynamics is that they may unconsciously not want the individual to recover because this would affect the family members/members own role in the

Provide information about enabling behavior, addictive disease characteristics for both user and nonuser.

Identify and discuss sabotage behaviors of family members.

relationship. Additionally, they may receive sympathy/attention from others (secondary gain). Encourage participation in therapeutic writing; e.g., journaling (narrative), guided or focused. Provide factual information to client and family about the effects of addictive behaviors on the family and what to expect after discharge. Serves as a release for feelings (e.g., anger, grief, stress), helps move individuals forward in treatment process. Many clients/SOs are not aware of the nature of addiction. If client is using legally obtained drugs, he or she may believe this does not constitute abuse.

Encourage family members to be aware of their own feelings, look at the situation with perspective and objectivity. They can ask themselves: Am I being conned? Am I acting out of fear, shame, guilt, or anger? Do I have a need to control? Provide support for enabling partner(s). Encourage group work.

When the enabling family members become aware of their own actions that perpetuate the addicts problems, they need to decide to change themselves. If they change, the client can then face the consequences of his or her own actions and may choose to get well. Families/SOs need support to produce change as much as the person who is addicted.

Assist the clients partner to become aware Partners need to learn that users habit may that clients abstinence and drug use are not or may not change despite partners the partners responsibility. involvement in treatment. Help the recovering (former user) partner Enabling behavior can be partners who is enabling to distinguish between attempts at personal survival. destructive aspects of behavior and genuine motivation to aid the user. Note how partner relates to the treatment team/staff. Determines enabling style. A parallel exists between how partner relates to user and to staff, based on partners feelings about self and situation. Useful in establishing the need for therapy for the partner. This individuals own identity may have been lost, she or he may fear self-disclosure to staff, and may have difficulty giving up the dependent relationship. Drug abuse is a family illness. Because the family has been so involved in dealing with the substance abuse behavior, family members need help adjusting to the new behavior of sobriety/abstinence. Incidence of recovery is almost doubled when the family is treated along with the client. Lack of understanding of enabling can result in nontherapeutic approaches to

Explore conflicting feelings the enabling partner may have about treatment; e.g., feelings similar to those of abuser (blend of anger, guilt, fear, exhaustion, embarrassment, loneliness, distrust, grief, and possibly relief). Involve family in discharge referral plans.

Be aware of staffs enabling behaviors and feelings about client and enabling partners.

clients and their families. Collaborative Involve in substance abuse treatment plan. Can be voluntary, court ordered, or via Department of Human Services involvement. Puts client/family in direct contact with support systems necessary for continued sobriety and to assist with problem resolution.

Encourage involvement with self-help associations, Alcoholics/Narcotics Anonymous, Al-Anon, Alateen, and professional family therapy.

NURSING DIAGNOSIS: Sexual Dysfunction May be related to Altered body function: Neurologic damage and debilitating effects of drug use (particularly alcohol and opiates) Possibly evidenced by Progressive interference with sexual functioning In men: a significant degree of testicular atrophy is noted (testes are smaller and softer than normal), gynecomastia (breast enlargement), impotence/decreased sperm counts In women: loss of body hair, thin soft skin, and spider angioma (elevated estrogen), amenorrhea/increase in miscarriages DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL: Substance Addiction Consequences (NOC) Verbally acknowledge effects of drug use on sexual functioning/reproduction. Sexual Functioning (NOC) Identify interventions to correct/overcome individual situation.

ACTIONS/INTERVENTIONS Sexual Counseling (NIC) Independent Ascertain clients beliefs and expectations. Have client describe problem in own words. Encourage and accept individual expressions of concern. Provide education opportunity (e.g., pamphlets, consultation with appropriate persons) for client to learn effects of drug on sexual functioning. Provide information about individuals condition.

RATIONALE

Determines level of knowledge, identifies misperceptions, level of concern regarding STDs, level of risk reduction, and specific learning needs. Most people find it difficult to talk about this sensitive subject and may not ask directly for information. Much of denial and hesitancy to seek treatment may be reduced as a result of sufficient and appropriate information. Sexual functioning may have been affected by drug (alcohol) itself and/or psychologic factors (such as stress or depression). Information can assist client to understand own situation and identify actions to be taken. Awareness of the negative effects of alcohol/other drugs on reproduction may motivate client to stop using drug(s). When client is pregnant, identification of potential problems aids in planning for future fetal needs/concerns. In about 50% of cases, impotence is reversed with abstinence from drug(s); in 25%, the return to normal functioning is delayed; and approximately 25% remain impotent.

Assess drinking/drug history of pregnant client. Provide information about effects of substance abuse on the reproductive system/fetus (e.g., increased risk of premature birth, brain damage, and fetal malformation). Discuss prognosis for sexual dysfunction; e.g., impotence/low sexual desire.

Collaborative Refer for sexual counseling if indicated. Couple may need additional assistance to resolve more severe problems/situations. Client may have difficulty adjusting if drug

has improved sexual experience (e.g., heroin decreases dyspareunia in women/premature ejaculation in men). Furthermore, the client may have engaged enjoyably in bizarre, erotic sexual behavior under influence of the stimulant drug; client may have found no substitute for the drug, may have driven a partner away, and may have no motivation to adjust to sexual experience without drugs. Review results of sonogram if pregnant. Assesses fetal growth and development to identify possibility of fetal alcohol syndrome/other drug harmful effects and future needs. There are concerns about placental abruption with the use of methamphetamine and cocaine.

NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self care, and discharge needs May be related to Lack of information, information misinterpretation Cognitive limitations/interference with learning (other mental illness problems/organic brain syndrome), lack of recall Possibly evidenced by Statements of concern, questions/misconceptions Inaccurate follow-through of instructions/development of preventable complications Continued use in spite of complications/adverse consequences DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL: Knowledge: Substance Abuse Control (NOC) Verbalize understanding of own condition/disease process, prognosis, and potential complications. Verbalize understanding of therapeutic needs. Identify/initiate necessary lifestyle changes to remain drug free. Participate in treatment program including plan for follow-up/long-term care.

ACTIONS/INTERVENTIONS Learning Facilitation (NIC) Independent Be aware of and deal with anxiety of client and family members. Provide an active role for the client/SO in the learning process; e.g., discussions, group participation, role-playing. Provide written and verbal information as indicated. Include list of articles, books, Internet sites, special TV programs related to client/family needs and encourage reading and discussing what they learn. Assess clients knowledge of own situation; e.g., disease, complications, and needed changes in lifestyle.

RATIONALE

Anxiety can interfere with ability to hear and assimilate information. Learning is enhanced when persons are actively involved. Helps client/SO make informed choices about future and can be a useful addition to other therapeutic approaches.

Assists in planning for long-range changes necessary for maintaining sobriety/drugfree status. Client may have street knowledge of the drug but be ignorant of medical facts. Facilitates learning because information is more readily assimilated when timing is considered.

Pace learning activities to individual needs.

Teaching: Disease Process (NIC) Review condition and prognosis/future expectations. Discuss relationship of drug use to current situation. Educate about effects of specific drug(s) used; e.g., PCP is deposited in body fat and may reactivate (flashbacks) even after long interval of abstinence; alcohol use may result in mental deterioration, liver involvement/damage; cocaine can damage postcapillary vessels and increase platelet aggregation, promoting thromboses and Provides knowledge base from which client can make informed choices. Often client has misperception (denial) of real reason for admission to the medical (psychiatric) setting. Information will help client understand possible long-term effects of drug use.

infarction of skin/internal organs, causing localized atrophie blanche or sclerodermatous lesions. Discuss potential for reemergence of withdrawal symptoms in stimulant abuse as early as 3 months or as late as 912 months after discontinuing use. Even though intoxication may have passed, client may manifest denial, drug hunger, and periods of flare-up, wherein there is a delayed recurrence of withdrawal symptoms (e.g., anxiety; depression; irritability; sleep disturbance; compulsiveness with food, especially sugars).

Inform client of effects of disulfiram (Antabuse) in combination with alcohol intake and importance of avoiding use of alcohol-containing products; e.g., cough syrups, foods/candy, mouthwash, aftershave, cologne.

Interaction of alcohol and Antabuse results in nausea and hypotension, which may produce fatal shock. Individuals on Antabuse are sensitive to alcohol on a continuum, with some being able to drink while taking the drug and others having a reaction with only slight exposure. Reactions also appear to be dose-related. Promotes individualized care related to specific situation. Cranberry juice and ascorbic acid enhance clearance of PCP from the system. Substances that have the potential for liver damage are more dangerous in the presence of an already damaged liver. Long-term support is necessary to maintain optimal recovery. Psychosocial needs and other issues may need to be addressed.

Review specific aftercare needs; e.g., PCP user should drink cranberry juice and continue use of ascorbic acid; alcohol abuser with liver damage should refrain from drugs/anesthetics or use of household cleaning products that are detoxified in the liver. Discuss variety of helpful organizations and programs that are available for assistance/referral such as AA, Dual Recovery Anonymous, Narcotics Anonymous.

POTENTIAL CONSIDERATIONS following acute care (dependent on clients age, physical condition/presence of complications, personal resources, and life responsibilities) ineffective [individual]/family Therapeutic Regimen Managementdecisional conflicts, excessive demands made on individual or family, family conflict, perceived seriousness/benefits.

ineffective Copingvulnerability, situational crises, multiple life changes, inadequate relaxation, inadequate/loss of support systems. readiness for enhanced family Copingneeds sufficiently gratified and adaptive tasks effectively addressed to enable goals of self-actualization to surface. (Physical needs depend on substance effect on organ systemsrefer to appropriate medical plans of care for additional considerations.)